Virtual Care Nursing:

The Wave of the Future

Beth Cloyd, DNP, MBA, RN, NEA-BC, FACHE, and
Julia Thompson, PhD, APRN, CNOR, CIP

There is a need to create new and innovative models of care to meet the growing
demands of patients and nurses. New technologies bring about novel and flexible
ways of working. One innovative strategy is the use of virtual care nursing delivery
model. Virtual care nursing operationalizes technology, supports clinical decision-
making processes, continuity of care, and patient safety and provides a work
environment conducive for keeping technically competent and highly educated
nurses engaged at the bedside.

T
he health care landscape has continued to un- back to the 1900s were reported primarily as tele-
dergo rapid change to meet the growing de- phonic, transmitting electrocardiogram tracings, and in
mands of payers and patient care. Payer the 1940s, a hospital in Philadelphia used the tele-
expectations for quality and service at lower reim- phone to transmit radiographic images.6 Today the
bursement rates (value-based purchasing) and the technology allows for real-time exchange of informa-
increasing expectation for transparency has magnified tion through video and audio technology in any setting.
the problem.1 Hospitalized patients are increasingly
complex with higher acuity and co-morbid conditions.2
These growing demands come at a time when there is VIRTUAL CARE NURSING
an evolving nursing shortage. With the increasing de- The National Council of State Boards of Nursing de-
mand for nurses and a third of the workforce between fines telehealth nursing practice as “nursing delivered
the ages of 50 and 64 years, and 850,000 RNs expected through various telecommunications technologies,
to retire,3 the need to create new and innovative including high speed internet, wireless, satellite and
models of care is critical. tele-video communications.”7 Telehealth nurses, or
These models of care must take into consideration virtual care nurses, can provide care and services any
issues contributing to RN burnout, needs of the place where telephonic and/or video technology can
millennial workforce, and how to balance the expertise be deployed. Generally, the video technology includes
of new graduates and experienced nurses in the hos- a high-resolution 2-way camera and 2-way audio
pital work environment. Solutions that leverage tech- communication for the patient and virtual care nurse
nology and innovation need to be explored. to be able to see each other and have 2-way

TELEHEALTH
KEY POINTS
Telehealth refers to a range of health care activities that
are provided remotely using telecommunication and  New technologies allow innovative
other technologies. Telehealth has been defined by the strategies such as virtual nursing care to
Health Resources Services Administration (HRSA) as improve patient quality of care and
“the use of electronic information and telecommuni- engagement.
cations technologies to support long-distance clinical  Implementation of virtual care nursing
health care, patient and professional health-related requires an organized change management
education, public health, and health administration.”4 process.
The World Health Organization defines telehealth as
 The virtual nursing role offers an
“the use of telecommunication and virtual technology
opportunity for retention of nurses by
to deliver healthcare outside of traditional healthcare
providing a work environment that takes
facilities.”5
advantage of their clinical expertise without
Telehealth has been making its mark on the health
the physical demands of the bedside.
care community for decades. Early use cases dating

www.nurseleader.com April 2020 147

 communication. In addition, other professionals would CERTIFICATION
be able to create practice efficiencies with the use of the Certification is the formal process by which a certifying
technology available at the bedside. agency validates a nurse’s knowledge, skills, and abili-
There are many settings that a virtual care nurse ties in a defined role and clinical area of practice. At
can practice including, but not limited to, the home, this time, there is not a specialty certification for tele-
health care clinics, clinician’s offices, community-based health or virtual care nursing; however, in 2011, the
settings, schools, post-acute and long-term care set- AACN developed a certification for nurses working in
tings, correctional facilities, hospitals, nursing call a tele-intensive care unit (tele-ICU) monitoring/caring
centers, workplace settings, insurance companies, and for acutely/critically ill adult patients from a remote
mobile units.8 location.9 Tele-ICU certainly has a unique role, re-
sponsibility, and knowledge set requirement for nurses.
STANDARDS OF PRACTICE As virtual nursing practice in the inpatient and non-
There presently are 2 standards of practice written to ICU setting grows, there will need to be a systematic
govern telenursing practice, the American Academy of and validated way to assess the skills and expertise of
Ambulatory Nursing (AAACN) and the American nurses performing this role to assure patient safety and
Association of Critical Care Nurses (AACN). The quality patient outcomes.
AAACN recognizes telehealth nursing practice as a
nursing subspecialty of ambulatory care nursing and EARLY ADOPTERS
publishes The Scope and Standards of Practice for Professional There have been several hospitals that have been early
Telehealth Nursing. The AACN also has established adopters of virtual care nursing in the inpatient non-
standards of practice in their publication AACN TeleICU ICU setting. With the support of a HRSA grant, Cath-
Nursing Practice: An Expert Consensus Statement Supporting olic Health Initiatives in Colorado implemented a Vir-
High Acuity, Progressive and Critical Care.9 As the only 2 tual Integrated Care Team Model. Through their work,
standards of practice statements that address virtual they were able to identify 6 key roles and functions of the
care, we should be familiar with the practice standards virtual care nurse. These 6 key roles include:
as a basis for evaluating the practice requirements in
the inpatient non-ICU setting such as a medical-  patient education
surgical unit.  staff mentoring and education
 real-time quality/patient safety surveillance
EXPERIENCE REQUIREMENTS  physician rounding
Although experience requirements have not been  admission activities, and
specifically defined for an inpatient virtual nurse,  discharge activities11
leaders that have deployed virtual care nurses identify
the need for strong competencies in caring for complex Virtual care nurses have identified the need for
patients. Using Benner’s Novice to Expert Model, the strong clinical experience as an important element for
virtual nurse experience requirements would be in the success in the role. In addition, education and collab-
more advanced stages of proficiency defined as profi- oration with the bedside nursing staff are critical for
cient and expert. Having experience at the proficient successful adoption of the program. It takes time to
and expert levels provides the foundation for the vir- build trust and confidence with the “new” virtual
tual nurse to mentor, precept and coach the onsite member of the bedside care team. The hard wiring of
novice and advanced beginner nurses.10 Critical skills role responsibilities and inclusion of evidence-based
would include clinical knowledge, interpersonal practice protocols are essential for program success.
communication, and critical thinking. Other qualifi-
cations would include proficient computer and tech- VIRTUAL CARE NURSING: THE SOLUTION FOR
nology skills. HOSPITAL INPATIENT NURSING?
With the rising percentage of new graduates staffing
EDUCATIONAL PREPARATION inpatient units, the experience gap in the hospital
Presently, there is limited education in baccalaureate setting will only continue to grow.12 There are
programs on the role of virtual nursing including approximately 3 million nurses that are licensed in the
functions, requirements, and responsibilities of a virtual United States.13 The average age of a registered nurse
care nurse. Graduate program education is primarily was found to be over 50 years, and the majority are
limited to the role of the nurse practitioner in primary predicted to retire by 2030.14 The physical demands in
care and urgent care roles. As teleprofessional nursing the inpatient care setting are creating high turnover
roles and settings increase, the identification and in- and burnout. With the resulting increase in nursing
clusion of key clinical skills will need to be included in vacancy rates, the concern is that the nurse-to-patient
baccalaureate curricula to better prepare graduate ratio will begin to grow and results in increasing
nurses for their entry into practice. nurse fatigue and missed care.15

148 April 2020 www.nurseleader.com

 With this growing issue, traditional staffing solu- future workflows developed. It is important to set key
tions will no longer be possible or practical. Innovative milestones and accountabilities to keep the team on
strategies will be necessary, and the nursing community track and provide opportunities for celebration.
will have to adapt and change to embrace these solu- Strong nursing leadership must be demonstrated
tions. One such strategy is the expansion of telenursing, throughout the change process for successful adoption
or virtual nursing. Much like the nursing role in the and sustainability. This is particularly important if there
tele-ICU, the expansion of virtual care nursing on is a need to adjust bedside staffing ratios. If making
inpatient nursing units would provide support for the changes to staffing ratios, it is important to be
bedside nurse and enhance the patient’s experience by methodical in the change process. The nurses must feel
providing increased patient interactions, by both the comfortable with the technology and trust the support
bedside nurse and the virtual care nurse. the virtual care nurse provides in day-to-day care.
The virtual care nurse does not replace the bedside The education of other members of the health care
nurse, but rather provides added support in the aspects team is also essential. Physicians, patients, and families
of care that do not require physical interventions. To must be included in the education of how to access the
help mitigate some of the staffing challenges facing the virtual care nurse as well.
non-ICU inpatient units (med-surg units) virtual care Nursing leadership should also explore other uses of
nurses can be used to support the bedside nurse to technology to optimize the efficiency of other disciplines
include tasks such as admission history, care plan in the patient care environment, for example, phar-
development and maintenance, patient education macy, physicians, case management, and social work.
including disease management, medications and
discharge, discharge planning, mentoring and pre- FUTURE RESEARCH
cepting new graduates, and implementation of evi- At present, the research on virtual care nursing and the
dence based practices. workforce is in its infancy. There are many important
Collaboration between the bedside care team and considerations of the use of technology in nursing that
the virtual nurse is important to prevent redundant should be explored to demonstrate the efficacy of vir-
work or create gaps in care. In addition, it allows for tual care nursing in various settings. Virtual nursing
better support of best practices and the ability to review workforce research topics that should be considered
and maintain the patient care record and patient care include, but are not limited to:
plan with current evidence-based interventions.
The virtual nursing role would potentially allow for  Nurse leader support and virtual teams
the retention and delay of retirement of experienced  Virtual nursing care and the quality and satisfaction
nurses by providing an environment that took advan- of the patient experience
tage of their clinical expertise without the physical  Virtual mentoring relationships and new graduate
demands of the bedside. With the looming gap be- nurses’ transition into professional practice
tween complexity of patients and the experience level  Use of virtual nurses’ and the impact of onsite staff
of nurses, this provides significant opportunity for satisfaction
expert nurses to contribute to care and share knowl-  Professional communication through remote
edge by mentoring and precepting novice nurses. technology.

CHANGE MANAGEMENT
The implementation of any patient care innovation SUMMARY
requires an organized change management process. The staffing models in the inpatient care setting have
The bedside implementation team should include shown little change over the last few decades; with
frontline bedside staff, nursing leaders, and quality and patient complexity and declining nursing experience,
safety staff. The process should be inclusive and is key nursing leadership should explore innovative changes
to the development of a successful change process. The in staffing models. Leveraging the use of technology
team’s key roles and functions would include delinea- must be considered as a part of the solution. Nursing
tion of each member’s responsibilities. In addition, how leaders must be familiar with change management
the virtual care nurse would provide precepting, models to guide this implementation of innovative
coaching, patient rounding including interdisciplinary change processes.
rounds, and other quality and safety initiatives such as
double verification of high-risk medications, evidence-
REFERENCES
based practices for hospital-acquired conditions such 1. Centers for Medicare & Medicaid Services. The Hospital Value-
as central line-associated blood stream infection and Based Purchasing (VBP) Program. August 2, 2018. Available
catheter-associated urinary tract infection need to be at: https://www.cms.gov/Medicare/Quality-initiatives-patient-
explored. Current workflows should be examined, and assessment-instruments/value-based-programs/HVBP/

www.nurseleader.com April 2020 149

 hospital-value-based-purchasing.html. Accessed September 11. Schuelke S, Aurit S, Connot N, Denney S. Virtual nursing: the
12, 2019. new reality in quality care. Nurs Adm Q. 2019;43(4):322-328.
2. American Hospital Association. Reconfiguring the Bedside Care 12. The Advisory Board. The Experience-Complexity Gap.
Team of the Future. AHA Care Team of the Future Roundtable. 2019. Available at: https://www.advisory.com/-/media/
2013. Available at: https://www.aha.org/system/files/content/1 Advisory-com/Research/NEC/Success-pages/2019/NEC-
3/beds-whitepapergen.pdf. Accessed October 28, 2019. experience-complexity-excerpt.pdf. Accessed November 1,
3. Buerhaus PI, Auerbach DI, Staiger DO, Muench U. Projections 2019.
of the long-term growth of the registered nurse workforce: a 13. Grant R. The U.S. Is Running Out of Nurses. February 3, 2016.
regional analysis. Nurs Econ. 2013;31(1):13-17. The Atlantic. Available at: https://www.theatlantic.com/
4. HRSA. What Is Telehealth? How Is Telehealth Different From health/archive/2016/02/nursing-shortage/459741. Accessed
Telemedicine? 2019. HealthIT.gov website. Available at: November 5, 2019.
https://www.healthit.gov/faq/what-telehealth-how- 14. National Council of State Boards of Nursing, The 2015
telehealth-different-telemedicine. Accessed October 15, 2019. National Nursing Workforce Survey. J Nurs Reg. Available at:
5. Davis T, Barden C, Dean S, et al. American Telemedicine https://www.ncsbn.org/2015ExecutiveSummary.pdf.
Association guidelines for TeleICU operations. Telemed J E Accessed November 15, 2019.
Health. 2016;22(12):971-980. 15. Tschannen D, Kalisch BJ, Lee KH. Missed nursing care: the
6. Bashshur RL, Goldberg MA. The origins of telemedicine and impact on intention to leave and turnover. Can J Nurs Res.
e-Health. Telemed J E Health. 2014;20(3):190-191. 2010;42(4):22-39.
7. The National Council of State Boards of Nursing (NCSBN)
Position Paper on Telehealth Nursing Practice. Approved by Beth Cloyd, DNP, MBA, RN, NEA-BC, FACHE, is chief
the Delegate Assembly August 1997. Editorial Update April nursing officer at Banyan Medical Systems in Omaha,
2015. Available at: https://www.ncsbn.org/3847.htm.
Nebraska. She can be reached at [email protected].
Accessed October 15, 2019.
8. American Telemedicine Association. Telehealth Nursing Fact Julia Thompson, PhD, APRN, CNOR, CIP, is
Sheet. April 2018. Available at: https://higherlogicdownload. administrative director, research & sponsored programs,
s3.amazonaws.com/AMERICANTELEMED/3c09839a-fffd-46 at Harris Health System in Houston, Texas.
f7-916c-692c11d78933/UploadedImages/SIGs/Telehealth_
Nursing_Fact_Sheet_04_25_2018.pdf. Accessed November 2, Note: The authors declare they have no conflicts of
2019. interest relevant to this paper.
9. American Association of Critical Care Nurses. AACN TeleICU
Nursing Consensus Statement. Available at: https://www.
aacn.org/nursing-excellence/standards/aacn-teleicu-nursing- 1541-4612/2020/$ See front matter
Copyright 2019 by Elsevier Inc.
consensus-statement. Accessed November 5, 2019.
10. Benner P. From novice to expert. Am J Nurs. All rights reserved.
1982;82(3):402-407. https://doi.org/10.1016/j.mnl.2019.12.006

150 April 2020 www.nurseleader.com